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f <br /> O 110 111 <br /> ORIGINAL STATE OF CALIFORNIA hl y <br /> 1 THE RESOURCES AGENCY Q /� c i'.� w#t�a7,Yc�'' <br /> File with DWR DEPARTMENT OF WATER RESOURCES <br /> No. O 9`�1�6 t. <br /> z <br /> WATE WELL DRILLERS REPORT <br /> State Well No StjI ", <br /> ," Ynt+re of Intent Na. D <br /> d Inca:Permit No.or Due 1 Othe. Well No._ r as7. <br /> (1) OWNER: Name (12) WELL LOG: Total dep .D[Dm of eomDletad. <br /> 1, <br /> from ft. to k. Formation (Des by color. chareeter. A20 or aeeelal <br /> Addles <br /> I _ ' ry•f' w <br /> City_ '�-' <br /> (2) L TI F Lb, (See instructions): _ <br /> g Owner's SV.,I Number - <br /> 8 Chan � � <br /> Well address If diS nt From ave - <br /> Tuwnshlp Range Sect; <br /> sance Im cities, ■ railroad fe s,etc <br /> Dlt <br /> i - I <br /> l"Irv`. <br /> r ' <br /> (3) TYPE OF WORK: � •�� <br /> 1 <br /> E. <br /> z.P <br /> New well)�Dcepentnit ❑ , <br /> Reconstrucdon ❑ _ 5 <br /> W Rernnditioning ❑ ? <br /> Horizontal Well ❑ _ <br /> Is Destmction ❑ (Describe '�•` <br /> destruction mueriab - _ <br /> procedures to Item 1 <br /> 1 <br /> (4) PROPOSED ,p afi <br /> Domestic <br /> Irrigallon�\ <br /> Industria. O ❑ <br /> �I: t <br /> T Well ❑ - <br /> Municip } <br /> WELL•LOCATION SKETCH Other ❑ <br /> (S) EQUIYMENTr (6) GRA PAM <br /> Roury ❑ <br /> Reverse ❑ ❑ No Size <br /> Cable Air ❑ er of bore <br /> Other ❑ Hucket ❑ <br /> d 7ryo <br /> (7).CASINC INSTALLEDt (81 ERFOAA 'Sr <br /> Steel Plasde ❑ Type of pe o or a of sero'e _ <br /> ✓' s <br /> Frorn To To <br /> Dia. Gr F - <br /> ft. ft in. Wall ft siz <br /> (g) WELL SEAL: <br /> %V_surface sanityry seal provided? Yes ❑ <br /> No if yes, m depth k• - <br /> (t. <br /> Were strata sealed against pollution? Yes f] n ❑ Interval 1 19 ComPlet l9 f <br /> \Nark started + <br /> Method of sealin <br /> ft WELL DRIL ESTATEMENT: <br /> (10) WATER LEVELS, u Thwell w drflld uau mV to risdicrio.r and this rt O rt o/ <br /> true to the pe <br /> Depth of first water, if kmmy <br /> ft. krowledlie r helm. <br /> Standla[ level sker well eomDletio _ e <br /> SIGNED (\V'1 e l <br /> (11) WELL TESTS: vn 1( ves by wham? <br /> Type-ell <br /> ltestst made? Yes p ❑ Bailer ❑ Air lift ❑ NA. <br /> y PumP'� �{Yersa or rztioa) (T or Dri ) <br /> ft. At end nl test R <br /> - - De h o w r at art of to C.�{-u— Addles <br /> Du +rce 1/min her hour Nater tem peri rive__ <br /> City <br /> CI,,_1 analysis made? Yes C NoIf ses. by whom? Date of this reM <br /> s No If ves. ..trach-p, to this retort Licetttt No <br /> 111., electric lo[ made. Yes ❑ ' <br /> ED FORM <br /> DWR lye u[v. •vet IF ADDITIONAL SPACE IS NEEDED. USF NEXT CONSECUTIVELY NUMBER <br /> - r :n <br />